Mechanical ventilation

Tracheostomy: timing and care

Reviewed Nov 2026·2 references
New· views rounded down, updated weekly

Consider tracheostomy when ventilation is likely to be prolonged (usually after 7-10 days or earlier in severe neurological injury). Early routine tracheostomy does not improve survival. Know emergency management of a displaced or blocked tracheostomy.

At the bedside

Timed steps
  1. 1

    Decide

    Day 5-10

    Expected prolonged ventilation, failed weaning, poor airway protection (neurological injury), copious secretions, upper airway obstruction. Early (≤ 4 days) routine tracheostomy did not improve 30-day survival (TracMan).

  2. 2

    Technique

    Choose

    Percutaneous dilatational (bedside, bronchoscopic guidance, ultrasound to map vessels) vs surgical (difficult anatomy, coagulopathy, high PEEP needs). See module 37.

  3. 3

    Daily

    Care

    Humidification, inner cannula cleaning, cuff pressure 20-30 cmH2O, suction, stoma care, bedhead sign with tube size and type.

  4. 4

    Decannulation path

    Wean

    Cuff deflation trials, speaking valve, capping trials, then decannulation when secretions are managed and cough is effective.

  5. 5

    Displaced or blocked trach

    Emergency

    Call for help; O2 to face and stoma; remove inner cannula; pass suction catheter; if not patent deflate cuff, and if still not breathing remove the tube; oxygenate via mouth or stoma; reinsert or intubate orally (if not a laryngectomy).

Red flag · call your senior now
Tube displaced < 7 days after insertion (immature tract): high risk; experienced airway operator.
Red flag
Bleeding from stoma days after insertion: think tracheo-innominate fistula (sentinel bleed) – surgical emergency.
Pitfall
Forcing reinsertion into a false passage (surgical emphysema, no ventilation).
Pitfall
Confusing a laryngectomy (no upper airway) with a tracheostomy.
Pearl
Keep a spare tube one size smaller, tracheal dilator and suction at the bedside.

References

  1. 1

    Young D, Harrison DA, Cuthbertson BH, Rowan K. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation (TracMan). JAMA. 2013;309(20):2121-2129

  2. 2

    Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033-1056

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